Student Affairs - Forms

Students of Concern Referral

Early Alert Warning System

Students of Concern is an Early Alert Warning System designed to serve as a point of referral from faculty and staff who have identified students who are experiencing difficulty in their collegiate experience and as a result, are at risk of leaving the institution. Once a student has been referred, the Students of Concern Committee is responsible for identifying the College representative best positioned to intervene and assist the student. The Committee is charged with coordinating the support resources of the College to assist referred students in: maintaining satisfactory academic progress; getting connected to appropriate resources; becoming engaged in the campus community, and; maintaining their overall health and well-being.

1.Name and Referring Community Member

*

2.Phone

*

3.Email Address

*

4.Contexts in Which You Know Student

Check all that apply: *

Classroom

Advisor

Student Group

Athletic Team

Residence Life

Chaplain’s Office

Office of Student Activities

Wellness Center

Other (please specify)

5.Student Name

*

6.Age

*

7.College Status*

Freshman

Sophomore

Junior

Senior

Graduate Student

Don't Know

8.Area of Study/Major

*

9.Student’s Living Situation*

On-Campus

Off-Campus

Spouse/Partner

Parents

Roommate

With Child(ren)

Don't Know

Other (please specify)

10.Describe the reason for your referral. Please be as specific as possible:*